Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
When should we consider using acarbose for postprandial hypotension?
Primarily in neurogenic Orthostatic Hypotension patients, and less frequently in POTS patients, they give a history of dizziness and hypotension with meals. First, we like to confirm the cause and recommend the following, checking before and after BPs at baseline and then with the following: Try sm...
What is your approach to initiating and titrating midodrine for both inpatient and ambulatory settings?
It depends on the indication: Orthostatic Hypotension: 2.5 mg TID CC Inpatient - Check orthostatics SEATED 5', then Standing 1' 3' 5' about one hour after dosing. Increase by 2.5 mg every other dose until patient clinically not orthostatic or 10mg TID CC is achieved or seated hypertension or other s...
Should vasodilatory therapies be considered first-line in the management of hypertension in patients with severe aortic regurgitation?
Yes, ACEi or ARB or dihydropyridine Calcium channel blockers would be the preferred anti-hypertension medication classes in patients with HTN and significant aortic regurgitation. There is no role, however, for using these agents in patients with severe AR without HTN.
Should a toe-brachial index be obtained in lieu of resting ABI as an initial screen for PAD in high-risk patients such as those with longstanding diabetes or advanced age with stiffened vessels?
Yes, a TBI should be used instead of an ABI in patients with diabetes and chronic kidney disease as the ABI is likely to be inaccurate due to non-compressible vessels. An arterial duplex and TBI should be the test of choice in this patient population.
Should all pregnant patients with newly reduced LVEF <45% be referred as soon as possible to advanced heart failure given high risk for maternal morbidity/mortality in setting of suspected peripartum cardiomyopathy?
The ESC EURObservational Research Programme demonstrated that at six months, in women with peripartum cardiomyopathy: Left ventricular function recovery occurred in 46% of women, whereas 23% continued to have persisting and severe left ventricular dysfunction Re-hospitalization rate was one in 10, a...
What is your approach to weaning IABPs?
The weaning of IABP has varied tremendously across facilities and even providers. To my knowledge, there is no evidence-based method for weaning an IABP. However, there was a beautiful expert-consensus paper released recently that provides excellent scaffolding. Use Table 4 from the article below as...
What are your preferred ventilatory settings/mode(s) for patients with acute hypoxic respiratory failure presenting with severe biventricular dysfunction in cardiogenic shock?
This is a great question - and, unfortunately, one that doesn't have a robust evidence base upon which to formulate a particularly informed response (at least nothing that has looked a hard outcomes like mortality or duration of mechanical ventilation). I go back, however, to the basics and a mantra...
Which hemodynamic parameters can be used to titrate positive pressure ventilation in preload dependent settings such as RV failure, cardiac tamponade, HOCM or hemodynamically significant PE?
As this question alludes, the application of positive pressure ventilation influences cardiac hemodynamics. Key principles of these cardiopulmonary interactions are outlined nicely by Alviar and colleagues (1) in a well-done review. In contemplating this question, it is important to consider the sep...
Would you consider coronary artery calcium scoring or coronary CTA for asymptomatic elite competitive sports athletes undergoing routine screening visits, without a family history significant for coronary artery disease?
I think that would be a "bridge too far" given no family history of premature CAD if we are speaking about a young athlete. If we are speaking about an obese 65-year-old who recently retired and has decided to train for a marathon which has been his/her goal for many years, then yes, coronary calciu...
Should we have a lower threshold to consider revascularization of coronary lesions in athletes, compared to non-athletes?
Broad question, that may be best asked slightly differently; does CABG or PCI reduce cardiac events in asymptomatic athletes? My approach would be to treadmill stress (preferably MPI) and assess the arrhythmic, ischemic, symptomatic, and hemodynamic burden of disease with exercise stress. And, decid...